A retrospective 10 years‐ experience overview of dye laser treatments for vascular pathologies

Abstract Introduction The Flash‐lamp pulsed dye laser (FPDL) is nowadays considered the most precise laser currently on the market for treating superficial vascular lesions. In this study, we gathered data from 10 years of experience regarding dye laser treatment of patients presenting vascular malformations such as telangiectasia, rhinophyma, port‐wine stain, cherry and spider angioma and vascular tumours. Methods Subjects were enrolled from 2013 to 2023 based on the vascular anomalies they presented. They underwent different treatment sessions with the FPDL device. Results The age‐range distribution by vascular anomaly confirmed that haemangiomas are typical in children while rhinophyma is a condition very common in older adults. A difference in sex distribution showed that pathologies such as telangiectasias typically affect women whereas rhinophyma is more frequent in men. Most of the treatments interested the face area but no permanent side effects were registered. Conclusions Our 10 years of experience with FPDL demonstrated good results in a wide range of applications for the treatment of different vascular anomalies. The absence of long‐term side effects and bearable pain during the treatment makes it a valuable solution for the resolution of benign tumours also in very young patients.

F I G U R E 1 Overview of the ISSVA classification for vascular anomalies (modified from 4 ). In red, are those that could be treated with FPDL.
It is believed to be the gold standard treatment for many vascular problems for all these reasons. According to the International Society for the Study of Vascular Anomalies (ISSVA) classification, vascular anomalies could be divided into vascular tumours (caused by vascular endothelial cell proliferation) and vascular malformations (structural abnormalities). Within the first group, there are benign (e.g., congenital, or infantile haemangioma), locally aggressive or borderline (e.g., Kaposi's sarcoma and kaposiform haemangioendothelioma) and malignant (e.g., epithelioid haemangioendothelioma and angiosarcoma) formations. On the contrary, vascular malformations are divided into four types. The Simple type includes capillary, lymphatic, venous, and arteriovenous malformations. A particular lesion may have two or more simple vascular abnormalities in a combined type. The term 'major named vessels malformation' describes anomalies in the origin, course or quantity of major blood vessels with anatomical names. Symptoms other than vascular anomalies, such as soft tissue or skeletal abnormalities, such as leg-length discrepancy and segmental hypertrophy, can complicate vascular malformations in syndromes (such as Klippel-Trenaunay syndrome and Sturge-Weber syndrome). 4,5 Among these lesions, FPDL had been demonstrated to be effective in the treatment of capillary malformations especially when localised on the face. Moreover, it showed good results for the resolution of benign, and borderline vascular tumours such as infantile haemangiomas and Kaposi's sarcoma (see Figure 1). 6,7 Laser therapy can be performed using a variety of lasers, including pulsed dye lasers (PDL), carbon dioxide (CO2) lasers and neodymiumdoped yttrium aluminium garnet (Nd:YAG) lasers. These devices were typically suggested as an alternative when all other nonsurgical local therapies failed. 8 propranolol have been largely proven to be the first-choice drug for IH in paediatric patients. 15 The medication has an ideal safety profile and is extremely effective (up to 96%-98% after 6 months). As specified by the drug's summary of product characteristics (SmPC-European Medicines Agency), 16 infants between the ages of 5 weeks and 5 months should receive oral propranolol for a period less than 6 months. 17 For all those children who are not treated in this window time, no medication has now satisfactory results. That is why 585 or 595 nm laser treatments could be used to prevent scarring which is usually a reason for a social and psychological impact on a child's life.
Indeed, when haemangiomas occur in high-risk areas, such as near the eyes, throat, nose, or trunk (60%) possibly impairing their function, it is important for an accurate medical intervention. 17 In this study, we gathered data from 10 years of experience regarding dye laser treatment of patients presenting vascular malformations such as telangiectasia, rhinophyma, port-wine stain (PWS), cherry angioma (ruby angioma), spider angioma and vascular tumours like IH. With this overview, we wanted to highlight the advantages of flash-lamp pulsed dye lasers.

Enrolled population
For this scientific research, the subjects were enrolled from 2013 to 2023 based on the vascular anomalies they presented. Details are shown in Table 1 and Figure 3.  TA B L E 2 Protocol details by vascular anomaly. The number of sessions and the interval they were performed, the device settings, the endpoint and the common side effects are reported.

Clinical assessment
At the baseline and after the last treatment, high-resolution digital photographs of the treated area were taken.

Multispectral assessment
An optical evaluation of the skin structures to monitor the effects of treatment was performed using an in vivo multispectral skin imaging with Antera 3D (Antera 3D; Miravex Limited, Dublin, Ireland).
This tool uses a computer-assisted reconstruction of skin surfaces and multidirectional lighting to assess the melanin and vascular components.

Workflow
Before treatment the interested area was cleaned removing all impurities that could interact with the light radiation (make-up, lotions, deodorants, ointments etc.) and patients were advised not to use cosmetics for 48 h prior to treatment as a precaution.
A skin test was performed before the beginning of the treatment to establish the proper therapy for every patient. Topical anaesthesia was not required. Indeed, patients usually well tolerated the treatment thanks to the skin cooling systems used before, during, and after the procedure.
Normally, the procedure foresees passing the handpiece on the skin's surface with overlapping areas up to 20%. When treating areas close to bone surfaces (forehead, cheekbones, etc.), special caution was used because these areas reflect the laser light, increasing the amount of energy dissipated. To do so, the fluence was reduced as much as necessary. Wads of cotton wool soaked in fresh water should be used to cover the teeth when treating the peri-labial region or the cheeks.
Depending on the region, energy fluence, skin type, and pulse duration, PDL therapy could cause erythema, oedema, purpura, crusting, blistering, hyper-or hypopigmentation, and in rare cases, scarring.

Device and protocols
Patients underwent different treatment sessions with the FPDL device (Synchro VasQ, DEKA, Florence, Italy) as indicated by Table 2. The device was provided with a skin contact sensor to assure the best results. A jet of air as the cooling system (Cryo6, Zimmer) was applied to the treated area to reduce oedema and inflammation during the treatment.
F I G U R E 4 Vascular anomalies divided by body area affected. There are pathologies typical of the face area (e.g., spider angiomas, telangiectasias) and others most common on the trunk and limbs (e.g., port wine stains, cherry angiomas).

Post-treatment care
After 4/5 days from the end of the treatment, patients were visited for a control. Right after the last session, a slight compression of the skin with cold wet gauzes or cooled by a jet of air from the cooling system (Cryo6, Zimmer) was applied to the treated area to reduce oedema and inflammation. Moreover, without massaging, a non-cortisone anti-inflammatory cream or unguent was applied (zinc oxide based). Patients were advised not to use hot water on the treated area for 24 h, play sports (swimming especially) for 48 h, rub the treated area, and be exposed to direct sunlight.

RESULTS
The general characteristics of the study population were analysed.
In Figure 2 is possible to see the age-range distribution by vascular anomaly. In general, haemangiomas are typical in children (≤10 years old) while rhinophyma is a condition very common in older adults (≥60 years old).
Moreover, is possible to appreciate a difference in sex distribution by vascular anomaly. So, there are pathologies such as telangiectasias that typically affect women. And, on the contrary, rhinophyma is more frequent in men (see Figure 3).
Most of the treatments interested the face area as shown in

Pre-and post-treatment assessment
The clinical and multispectral assessments were carried out for every patient at the baseline, during the process and after the last session. We here show some exemplificative clinical cases. Figures 6, 7 and 8 report port wine stain case progresses after treatment with FPDL. An almost full resolution is visible with no permanent side effects. Figure 9 shows an IH while Figures 10 and 11 report spider and cherry angiomas, respectively. Lastly, Figure 12 is a rhinophyma resolution.

F I G U R E 6
Clinical assessment of a shoulder port wine stain in a female patient. The progression from A to E shows an almost full resolution. A = before treatment; B = after one treatment; C = after two treatments; D = after four treatments; E = after six treatments.

F I G U R E 7
Clinical assessment of a breast port wine stain in a female patient. The progression from A to G shows an almost full resolution. A = before treatment; B = right after treatment (the endpoint with purpura is visible); C = after one treatment; D = after two treatments; E = after three treatments; F = after four treatments; G = after six treatments. Therefore, its use in other dermatological disorders like keloids is possible. 1,19,20 Nowadays, the optimization of laser devices, parameters and settings has led to the employment of higher fluences for targeting deeper structures. 21 As Bruscino et al. 11 reported, the choice of longer pulse widths and wavelengths and the use of cooling systems have permitted dermatologists to achieve faster results. 22 Even if this choice is still effective and with few side effects, we decided to further F I G U R E 1 2 Clinical (A) and multispectral (D and E) assessment of a male patient presenting rhinophyma. The melanin (D) and vascular (E) components are highlighted with Antera 3D (Antera 3D; Miravex Limited, Dublin, Ireland) system before and after the last treatment. A full resolution of the vascular anomaly is visible with and without image filters. A = before treatment; B = right after treatment (the endpoint with purpura is visible); C = after two treatments; D = multispectral melanin component, before and after the last treatment; E = multispectral vascular component, before and after the last treatment.

CONCLUSION
Our 10 years of experience with FPDL demonstrated good results in a wide range of applications for the treatment of different vascular anomalies. The absence of long-term side effects and bearable pain during the treatment makes it a valuable solution for the resolution of benign tumours also in very young patients.

Study limitations and future perspectives
Despite the good aesthetic results, the procedure's high price may put a limit on its utilisation.

CONFLICT OF INTEREST STATEMENT
BMP and TZ are employed at El.En. Group. The other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

ETHICS STATEMENT
The study was conducted in accordance with the Declaration of Helsinki. As the device has been an already CE-marked device since 2019, ethical review and approval were waived for this study. Informed consent was obtained from all subjects involved in the study.